Like trying to put out a wildfire

Chlamydia is the sexually transmitted infection du jour in our clinic. On a daily basis I probably encounter at least one, often 2, and sometimes 3-4 women per day who have it. For the majority of the women I see, learning that they have an STI is often like a wake-up call. They usually get treated, then their partner gets treated, and then, to their credit, they often remain STI free for the rest of their pregnancy. Many of them choose to break-up with the partner that infected them, or stop sleeping with him/her altogether, or else become religious in their condom use. However, sometimes it’s not that easy. In one woman whom I’ve been taking care of since I started my new job (i.e. over 5 months now) she’s had chlamydia 3 times. In other words, she’s been reinfected twice after being treated, probably because her partner has 1) never been treated or 2) keeps getting reinfected himself. In another case, a woman has been treated twice for chlamydia now because her husband has multiple wives, and obviously we still haven’t gotten all of them treated yet. I spend much of my day talking myself hoarse about safe sex, strict condom use and the importance of getting partners treated. And then the CDC releases studies which show that nearly half of all adolescent African American girls have had at least one STI, compared to only 20% of all white and Mexican-American teenagers (keep in mind that the predominant populations in our clinic are African American and Hispanic). It makes me want to cry. We get fifteen minutes alloted to us on our templates to take care of an OB or gynecology revisit. That’s fifteen minutes to conduct an entire interval history, address any questions or concerns, follow-up on lab results and order upcoming tests, do the physical exam (listen to the fetal heart tones, Leopold’s, measure the fundal height etc.), and then write a note on it. Fifteen minutes is barely enough time to tell a woman she has chlamydia, what the treatment is, how important it is that she get treated and then not reinfect herself, how crucial it is that her partner is also treated, and how essential condom use with future partners is. It’s like the tip of the ice berg when really these women need so much more than just counselling on safer sex and strict condom use. They need to learn how to assert their power—how to put their foot down with a partner that may potentially be cheating on them, how to say emphatically “no condom, no koochie” and not buckle in to seduction or pressuring, how to choose and insist on respectful partners. It’s like staring at a huge, roaring wildfire, and your only weapon against it is a tiny fire extinguisher. So what do we do? Keep trying to extinguish the chlamydia, one case at a time, and keep talking ourselves hoarse about safe sex.

The myth goes something like this: if you sleep around, you’ll get an STI, and that only bad girls sleep around, so they deserve the STIs they get while the good girls save themselves for marriage and remain pure. But what if the guy you saved yourself for happens to have an STI (like the faithful wife who has a husband with multiple wives, or the woman who kept getting reinfected from her fiance)? The problem we’re seeing is not women with multiple partners who keep contracting STIs because they’re “sleeping around”. These women care about themselves, but they’re often caught in a power imbalance which makes it very difficult for them to insist that their partners get treated, or that their partners are honest with them about their activities, or that their partners wear condoms. So long as the partner is never treated, the woman will keep getting the STI, even though she’s in a committed relationship and is sleeping with only him. Sure, you have the occassional standout who’s had dozens of partners, but for the most part when you ask about the number of sexual partners they’ve had, it’s relatively low. …it’s just that their partners sometimes have a different idea of what “monogamous” means than they do, or else their partners won’t get treated because they don’t believe they have anything (STIs in men are often notoriously asymptomatic). It’s also a lack of education; you can sleep with as many people as you like, and so long as you protect yourself from STIs through strict condom use, you’ll be fine. So “sleeping around” itself isn’t the problem, it’s lack of condom use, really. And it’s not a lack of caring about themselves, it’s a lack of power, and that’s very difficult to fix.

See, but it is a lack of caring about their body, it’s also a lack of respecting their body- fueled by feeling powerless. They aren’t actually powerless, they just feel like they are because many women are taught either by example, or situation that they are supposed to be submissive, and give in to sexual pressure, even in marriage. They really aren’t powerless, even in a monogamous relationship. In your example, the woman keeps getting re-infected because the partner won’t get treated. There is a simple, self-respecting solution- STOP sleeping with him until he gets treated. Either he’ll get treated and the woman will sleep with him again, or he won’t and she won’t which could allow other relationship issues (like how he got infected in the first place) to be dealt with. Same with requiring who you sleep with to use condoms. Either he uses a condom or NO sex. These women in actuality aren’t powerless, they just feel that way. Maybe they were abused, maybe their mother was the doormat in the relationship, maybe their was no father figure, and they need that emotional void filled by a man; there are endless reasons a woman feels that way. You’re difficulty isn’t fixing that they have a lack of power, feeling that they have a lack of power is a symptom of a deeper issues, and that’s what you have difficulty fixing in a matter of fifteen minutes a month.

When I said I don’t get the sleeping around thing, I wasn’t referring strickly to women sleeping around. I was referring to a woman putting up with sleeping around. I wasn’t meaning to push the “good girl, bad girl” myth. Sorry my thought process wasn’t clear.

The real issue isn’t that they ARE powerless, it’s that they FEEL powerless, and that very likely stems from a lack of respect of themselves and their bodies. Maybe that lack of respect stems from prior abuse, maybe it’s because their father was absent or emotionally distant, maybe their mother was treated like a doormat by their father or various boyfriends, the reasons are endless. If they cared more about their bodies, and themselves, the solution to getting re-infected from their partner is simple. No treatment, No sex. No condom, no sex. A woman, even in a monogamous relationship certainly possesses the power to say/act that way. They just feel like they don’t. Feeling powerless is really a symptom of deeper issues, and that’s what you can’t fix in fifteen minutes a visit.
My thoughts weren’t well articulated in my first comment. I wasn’t trying to buy into the “good girl/bad girl myth” I meant I didn’t understand why women put up with their partner sleeping around. Again, it IS about respecting oneself, and body; caring about oneself. If a woman respected herself more, and felt that she possessed the power to say, “I’m not putting up with this, you won’t treat my body this way,” she wouldn’t continue to be re-infected. Maybe I’m to into the psychology behind the behavior, as opposed to the behavior itself.

In practice, it sounds like it is easy to “just say no” but the clients I have cared for who are repeatedly infected live in situations far different from what I have personal experience with. If you are dependent on your partner for housing, food, status, protection for your children, it might be hard to say “no condom, no sex.” Getting an STI might be the price you pay for support. It might be hard to even go to your partner and tell him he gave you chlamydia, and admitting you have it might open you up to all sorts of accusations of cheating yourself. It’s not just a self esteem issue but also one of self preservation.
One way I try to put out this wildfire is that as a family doc I feel comfortable prescribing for the partner – basically I just document medication allergies for the partner and write a double prescription for the woman who is my own patient. I find the hang up is often in getting the male partner somewhere to have a full history and physical, and then sometimes whoever is treating the partner won’t treat without testing (and testing is not as accurate in men, so then sometimes they don’t get treated because their test is negative, or the person who sees the partner isn’t knowledgeable and gives the wrong meds, or doesn’t understand that they are there for STI treatment, or the partner doesn’t explain what is wrong accurately – I’ve had more than one partner go to the doctor, not tell them they are there for history of STI exposure, have the doc not realize that’s what they are supposed to be treating, and then the partner comes home and tells my own client, the female partner that the “doc said I’m fine” and next thing you know, my client is infected again). Often, the underserved women I take care of have Medicaid at least, but the male partners don’t, and getting treatment is really difficult for some of them. Then, those that have access to treatment don’t want to go, are embarrassed, etc. etc. I’m lucky in my own practice to be able to prescribe for both partners a lot of the time. When I can’t, I role play with my client ways to tell her partner and ways to encourage them to get treatment, and ways to keep themselves safe (sometimes, at least in pregnancy, women are able to make the point to their partner that it’s important to keep the baby safe.)
In these hard situations, I find that telling the woman in front of me that she just has to say no is not always that useful. Providing access for partner treatment is far more helpful!

At our clinic we have a male STI clinic that’s open every Tues. night, so whenever we have a patient who has an STI, we give the woman a referral to the clinic for her partner. But getting them to actually go to the clinic is a whole other matter. All of the attenuating factors you mentioned which make it so hard to get the partner treated are all part of the power imbalance that we see, and I agree that it’s because of all of those things that the rates of STIs are so high in our clinic. I wish I could prescribe drugs for men because then I could do what you do, but I think a prescription for a man coming from a CNM would look a little weird. I’m not sure if it’s even legal (I’ll have to check that out), but at this point I don’t feel comfortable prescribing for people I haven’t seen. However, the CDC does recommend that partner-provided therapy is the best way to extinguish STIs. Role-playing is also a good idea, though. I’ll have to start incorporating that into my practice more.

You know, since even the CDC says partner provided therapy is the way to go, I wonder if units that treat a lot of women should look into writing protocol and standing orders for partner therapy. I usually just write a script in the woman’s name for twice the dose (usually for chlamydia, so zithromax, 2 gms take as directed) and give the woman written instructions on how she and her partner should take the medicine. If we are talking gonorrhea, we offer low cost ceftriaxone in the office (I practice in a fairly rural private practice, but care for a lot of medicaid clients whose partners usually have no insurance.) I wonder if there is a way in a big clinic setting to write some standing orders and protocols and just start providing partner therapy. I figure that having medicaid pay for the extra dose of zithromax is actually cost effective because then I don’t have to treat my own client repeatedly (I don’t know if medicaid would see it that way, though.)
I very much agree with you that stigmatizing the whole issue just doesn’t help – has to be treated more like “okay, here’s the problem, help me figure out the best way to help you fix it”
By the way, I really enjoy your writing and wish you’d blog more! (And I hope you don’t mind non-midwives chatting at you all the time.)

Thank you. I don’t mind the chatting at all. Thanks for reading. I wish I had more time to blog, too, but my job leaves me pretty drained most nights. It’s definitely a lot harder now than it was during my student days.